A rare anastomosis between the root of common hepatic artery and proper hepatic artery: implications for pancreaticoduodenectomy
Hepatic artery anomalies are often observed, and the variations are wide-ranging. We herein report a case of pancreatic cancer involving the common hepatic artery (CHA) that was successfully treated with pancreaticoduodenectomy (PD) without arterial reconstruction, thanks to anastomosis between the root of CHA and proper hepatic artery (PHA), which is a very rare anastomotic site.
A 78-year-old woman was referred to our department for the examination of a tumor in the pancreatic head. Contrast-enhanced computed tomography (CT) revealed a low-density tumor of 40 mm in diameter located in the pancreatic head. The involvement of the common hepatic artery (CHA), the root of the gastroduodenal artery (GDA), and portal vein was noted. Although such cases would usually require PD with arterial reconstruction of the CHA, it was thought that the hepatic arterial flow would be preserved by the anastomotic site between the root of the CHA and the PHA, even if the CHA was dissected without arterial reconstruction. PD with dissection of the CHA and PHA was safely completed without arterial reconstruction, and sufficient hepatic arterial flow was preserved through the anastomotic site between the CHA and PHA.
We presented an extremely rare case of an anastomosis between the CHA and PHA in a patient with pancreatic cancer involving the CHA. Thanks to this anastomosis, surgical resection was successfully performed with sufficient hepatic arterial flow without arterial reconstruction.
KeywordsRare anastomosis Pancreatic cancer Pancreaticoduodenectomy Arterial reconstruction
Common hepatic artery
Proper hepatic artery
The recent development of imaging modalities, such as three-dimensional computed tomography (CT) angiography, is helpful for better understanding vessel anomalies before surgery. Adequate knowledge of these variations would be of incredible help to the surgeon and interventional radiologist for avoiding unexpecting perioperative complications and unnecessary procedures [1, 2, 3]. Hepatic artery variations, including accessory right hepatic artery branching from the gastroduodenal artery, have previously been reported [4, 5, 6, 7, 8, 9]; however, to our knowledge, there are no previous reports of anastomosis between the root of the common hepatic artery (CHA) and proper hepatic artery (PHA). We herein introduce a case in which pancreaticoduodenectomy (PD) was performed without arterial reconstruction, thanks to anastomosis between the root of the CHA and PHA.
A 78-year-old woman was referred to our department for investigation of a tumor in the pancreatic head that was discovered upon a worsening of her diabetes. A physical examination revealed upper abdominal pain and jaundice. A laboratory analysis provided the following results: serum aspartate aminotransferase, 312 U/L (normal range, 13–30 U/L); alanine aminotransferase, 222 U/L (normal range, 10–42 U/L); lactate dehydrogenase, 266 U/L (normal range, 0–229 U/L); alkali-phosphatase, 3215 U/L (normal range, 0–359 U/L); γ-glutamyl transpeptidase, 835 U/L (normal range, 0–55 U/L); amylase, 12 U/L (normal range, 40–126 U/L); total bilirubin, 32.5 mg/dL (normal range, 0.4–1.5 mg/dL); direct bilirubin, 23.0 mg/dL (normal range, 0–0.2 mg/dL); albumin, 2.4 g/dL (normal range, 4.1–5.1 g/dL); prothrombin time (PT), 14.9 s (normal range, 11.0–15.2 s); activated partial thromboplastin time, 32.0 s (normal range, 25.2–35.2 s); hemoglobin A1c, 4.9% (normal range, 4.6–6.1%); and blood glucose, 166 mg/dL (normal range, 70–109 mg/dL). The serum level of CEA was normal, but the CA19–9 level was 297.3 U/mL (normal range, < 37 U/mL).
Histologically, as expected before surgery, the pancreatic head cancer invaded the root of the gastroduodenal artery (GDA) and PV; however, cancer cells were not invading the lumen of the GDA. The final diagnosis was pancreatic head cancer with the involvement of the CHA and PV, T3N0M0 stage IIA (UICC seventh edition) .
Some previous studies have reported that hepatic artery anomalies are often observed and that the variation is wide-ranging [4, 5, 6, 7, 8, 9]. The recent development of imaging modalities has enabled us to understand vessel anomalies preoperatively. A better understanding of the anatomy of vessel structures before surgery can help to avoid unexpected perioperative complications and unnecessary procedures [1, 2, 3]. Thus, adequate knowledge of these variations would be of incredible help to the surgeon and interventional radiologist .
Various hepatobiliary anomalies arise during the development process. During development, the coeliac axis is derived from the 10th ventral segmental artery and the superior mesenteric artery (SMA) is derived from the 13th segmental artery. The 11th and 12th segmental arteries normally regress [12, 13]. Variations occur during this development and regression of the ventral segmental arteries lead to multiple anomalies. Following normal development, the common hepatic artery usually arises as one of the three major branches of the coeliac axis. In adults, there are numerous anatomic variations of the hepatic arterial tree that result from the variable persistence of elements of the embryologic blood supply .
We always check the vessel structure anatomy before hepatobiliary surgery. In the present case, anastomosis between the root of the CHA and PHA was found. To the best of our knowledge, this is the first report of anastomosis between the root of the CHA and PHA that was identified prior to PD, although, it was unclear whether this developed congenitally or was acquired. Based on the observation that the pancreatic head cancer did not close the lumen of GDA histologically, it is considered that—in this case—anastomosis was congenital and arose in the development process.
In the present case, we considered that the hepatic arterial flow could be preserved if the CHA was dissected without arterial reconstruction due to anastomosis between the root of the CHA and PHA. After clamping both the CHA and PHA, sufficient hepatic arterial flow via this anastomotic site, which was almost equivalent to that before clamping, was confirmed by pulse-wave Doppler method on intraoperative ultrasonography. Although we were preparing for arterial reconstruction in the event that sufficient arterial flow could not be confirmed, the operation was successfully completed without arterial reconstruction, and the postoperative course was uneventful.
We presented an extremely rare case of an anastomosis between the CHA and PHA in a patient with pancreatic cancer involving the CHA. Thanks to this anastomosis, hepatic arterial flow was sufficiently preserved without arterial reconstruction after PD. The importance of a preoperative understanding of vessel anomalies should be emphasized.
TM and KI wrote the manuscript and performed the literature search. TM, KM, KY, SI, KH, and SS treated and observed the patient. KM, KY, SI, KH, SS, and HB supervised the treatment and postoperative management. All authors read and approved the final manuscript.
The authors declare that no funding was received for this study.
Ethics approval and consent to participate
Consent for publication
Written informed consent was obtained from the patient for the publication of this case report and accompanying images.
The authors declare that they have no competing interests.
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